1, __________________ (State Your Role), residing at  ________________________, being first duly sworn, state as follows:

I am the _____________________ (Your Role) of the Estate of ___________________ (“Decedent”) who died on ____________ (“Date of Death”).

At the time of death, the Decedent's domicile was  _____________________________, and the Decedent had resided in the State of ___________________ and was not a resident of any other state of the United States at the time of death.

The Decedent did not claim any state of domicile other than the State of _____________

on any instrument or Will executed within the two years prior to death.

Certificate(s) representing ___________________ were physically located in ________, at the time of the Decedent's death.

__________________

Maker of Affidavit

Subscribed and sworn to before me this __ day of ________, 20__.                      

_____________

Notary Public

My Commission Expires on: ______________